Low-Volume Hospitals Had Higher Reoperation Rate, Postoperative Complications in CRC

The reoperation rate for colorectal surgery, aimed at addressing colorectal cancer (CRC), was higher in low-volume hospitals (LVHs) compared with high-volume hospitals (HVHs) according to a study published in BJS Open. However, failure-to-rescue (FTR) rates were about the same across both LVHs and HVHs, indicating similar resources.

Postoperative complications occur in approximately 20% to 37% of colorectal surgeries, with emergency reoperation occurring in 6% to 8% and the risk of mortality being between 2% and 19% in all patients. Short- and long-term outcomes were found to improve in patients treated in HVHs.

"The difference in short-term outcomes between HVHs and LVHs has been thought to arise mainly from mortality rate after a complication has occurred that is [FTR], which has been reported to be lower in HVHs," the authors explained.

This study aimed to assess reoperation rate and FTR after emergency reoperation for colorectal surgeries in Finland that were elective.

Colorectal cancer | Image credit: UA Creative - stock.adobe.com

Adults aged 18 years and older who had colorectal surgery from January 1, 2006, to December 31, 2017, were assessed for this study. All patients came from the Hospital District of Helsinki and Uusimaa. Elective colorectal resection was assessed using surgical procedure codes that included right- and left-sided hemicolectomies, subtotal colectomies, and anterior rectal resections. Excluded surgeries included proctocolectomies and abdominoperineal resections. Reoperations were classified as those due to a suspected complication and related to the first operation.

The hospital that the patient used for their first operation was what was used to divide patients into HVH and LVH categories. Hospitals were classified as LVHs and HVHs based on the number of operations they performed in a year, with those who conducted more than 126 operations being classified as HVHs. FTR was defined as mortality within 90 days of reoperation for any cause. The Comprehensive Complication Index (CCI) reflecting the overall morbidity, length of stay (LOS), days outside of the ICU, overall survival, and permanent ostomy rate was used as the secondary outcome, with the primary outcome being the FTR.

There were 9429 patients included int his study who had a colorectal resection, of which 68.2% were performed at HVHs and 32.0% were performed in LVHs. A total of 4.1% of ptients had reoperations within 30 days, of whom 56.8% were operated on in HVHs, and 43.2% operated on in LVHs; 7.3% of patients had their reoperation in a different hospital type than their original surgery.

There were 284 patients who were propensity score–matched for 142 patients in both HVHs and LVHs. Patients in HVHs had more comorbidities than patients in LVHs prior to the propensity-score match. The index operation had no significant differences in procedures, though rectal resections (12.1% vs 7.1%) and protective ostomies (7.0% vs 3.6%) were more common in HVHs. Standardized mean difference (SMD) improved for most variables after propensity-score matching, which made the 2 groups more comparable. However, previous operations, myocardial infarction, previous thrombosis, and operative technique were not comparable after matching in the 2 groups.

HVHs (65.5%) and LVHs (62.0%) both had intra-abdominal infection as their most common finding after reoperation. This was followed by intra-abdominal bleeding (20.4% in HVHs; 14.8% in LVHs) and fascial rupture (13.4% in LVHs; 11.3% in HVHs). LVHs more often saw superficial wound infection after reoperation compared with HVHs (4.9% vs 0%). Resuturing of the anastomosis was more often performed in HVHs compared with LVHs (19.7% vs 11.3%).

LVHs were found to have higher rates of intra-abdominal infection (2.9% vs 1.4%), bowel obstruction (0.6% vs 0.1%), wound infection (0.2% vs 0%), and fascial rupture (0.6% vs 0.2%) that needed reoperation compared with HVHs. However, the rate of intra-abdominal bleeding was similar. FTR was also similar in both HVHs (7.7%) and LVHs (10.6%). The median CCI was higher in LVHs (29.6) vs HVHs (21.8) as well.

There were some limitations to this study. The retrospective design of the study leaves it open to patient selection bias and prognostic factors being imbalanced. This study only included patients who had elective colorectal resection for any indication. The risk of bias could have been increased due to interpreting mixed data.

The researchers concluded that reoperation rates were higher in patients who were operated on in LVHs. However, the FTRs being similar indicated that LVHs had the resources to perform reoperations due to colorectal complications, which should encourage the continued performance of elective colorectal surgery in LVHs.

"Removing elective colorectal surgery from LVHs could have negative consequences for the healthcare service in the area, so other options in improving care should be sought," they wrote. "These could include closer collaboration, standardized perioperative care and joint multidisciplinary teamwork between LVHs and HVHs."

Resource

Grönroose-Korhonen MT, Koskenvuo LE, Mentula PJ, et al. Impact of hospital volume on failure to rescue for complications requiring reoperation after elective colorectal surgery: multicentre propensity score-matched cohort study. BJS Open. Published online April 10, 2024. doi:10.1093/bjsopen/zrae025